Zimbabwe has set a goal of circumcising 1.2 million men by 2015 - a bold target for a country that has been slow to get its circumcision programme off the ground but is now rapidly making up for lost time.
When the national circumcision policy was launched two years ago there was widespread scepticism as to whether the country had the capacity to provide mass male circumcision, in view of a health system that had been starved of resources, drugs and equipment for years.
Tinashe Damba, 29, is one of almost 30,000 men who have taken advantage of the free circumcision scheme offered by the ministry of health in conjunction with Population Services International (PSI), an NGO, and other partners.
"I thought the circumcision procedure was going to be very painful but I did not feel a thing," said a relieved Damba after leaving the operating room at a clinic in the capital, Harare. The only pain he felt was when his penis was injected with the anaesthetic that made it numb during the procedure.
"I heard that if you get circumcised you have a better chance of not contracting the deadly HIV. It's not 100 percent prevention, but you reduce the chances of contracting that disease."
A large study in Kenya, South Africa and Uganda in 2006 found that the procedure could reduce a man's risk of contracting HIV through vaginal intercourse by as much as 60 percent.
Before Zimbabwe launched its campaign, male circumcision had only been available at private health institutions and mostly for reasons other than as an HIV intervention measure.
"Blessing in disguise"
Zimbabwe is not the only country that has been slow to introduce free male circumcision in state facilities. In neighbouring Malawi, the government has yet to implement mass male circumcision, while South Africa has been criticized for moving too slowly in developing a national circumcision strategy.
"I do not think we were too far behind other countries," said Minister of Health and Child Welfare Dr Henry Madzorera, "but then we were going through a rough patch politically and economically, and the public health system was close to collapse."
A health worker strike that began in November 2008 shut down public health services for several months. The loss of qualified nurses and doctors who left to work in other countries made it even more difficult to deliver the service.
The delay was, according to PSI circumcision programme manager Roy Dhlamini, a blessing in disguise. "Only very small pockets of the Zimbabwean population practice circumcision [as a cultural rite]. People needed to be educated on the benefits, so a nationwide campaign to sell male circumcision was launched."
The findings of research in Zimbabwe’s rural areas, published in the May issue of the Tropical Medicine & International Health journal, show that 52 percent of the men surveyed were prepared to undergo the procedure.
Dhlamini said Zimbabwe was also benefiting from the success and challenges of those who had started earlier, resulting in the lowest rate of "complications" - less than 1 percent - compared to a regional average of more than 3 percent.
Two years ago, the programme had the capacity to circumcise only eight people per day at its flagship facility, the Spilhaus Family Planning Centre in Harare. From the time a client walked into the centre included up to two hours of mandatory counselling and an HIV test, with another half hour for the procedure, to when he walked out without his foreskin.
Staff shortages were another major problem. "We only had eight doctors and 18 nurses, now we have 40 doctors and 160 nurses and training is ongoing," Dhlamini said. The ideal is to have at least a doctor and eight nurses at a health centre in each of Zimbabwe's 62 districts.
The programme currently has five stationary and two mobile centres. "People have been travelling from as far as 500 kilometres to the few centres available. We want to make it more accessible for them by establishing the district centres and taking the service to them, using the mobile centres."
The process also had to be speeded up. "We devised the Model of Optimising Volumes and Efficiency (MOVE), whereby doctors now work in teams of three - one anaesthetizes, the other carries out the procedure, and the third one bandages the penis," Dhlamini said.
This has reduced the operation to fifteen minutes and counselling now takes one and a half hours.
The campaign was largely financed by external donors but the cash-strapped government has also contributed. "This programme is part of the health delivery system. It is carried out primarily in already established government health facilities, and we provide the staff," Health Minister Madzorera said. The government will also pay allowances to those involved in field work.
Earlier in 2011, PSI and the ministry of education targeted adolescents older than 13 during school holidays, resulting in a 200 percent jump in the number of circumcisions. "We plan to repeat the exercise in the next school holidays," PSI’s Dhlamini said.
Nevertheless, some are still sceptical about whether circumcision will bring down the incidence of HIV. Mary Sandasi, Executive Director of the Women's AIDS Support Network (WASN), feels that male circumcision does not protect women and may lead some men, especially younger ones, to believe it is the silver bullet against HIV.
"Thirty years after the first AIDS case was identified we are still getting infections, even in countries where men are circumcised as infants, so this may not be the answer," she said, adding that the only solution for sexually active people is the correct and consistent use of condoms. "They need to remind men after the operation."
Health minister Madzorera said Sandasi's concerns would be valid in the absence of pre-circumcision counselling, which makes it clear that the procedure has to be used with other HIV prevention interventions.
"The message is repeated during the obligatory visits to a medical centre after the procedure. After these visits we keep on reminding those circumcised through multi-media campaigns, so there is no let-up."
Madzorera is confident the target can be reached. "The success to date of this programme is due to the fact that Zimbabweans are quick to adapt to new ideas. We have rural chiefs encouraging their people to get circumcised - that is a good sign."
This article was produced by IRIN News while it was part of the United Nations Office for the Coordination of Humanitarian Affairs. Please send queries on copyright or liability to the UN. For more information: https://shop.un.org/rights-permissions